Healthcare Provider Details

I. General information

NPI: 1215947031
Provider Name (Legal Business Name): LEANNA BRUEN WILLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 BLUE RIDGE RD SUITE 100
RALEIGH NC
27607-6475
US

IV. Provider business mailing address

2605 BLUE RIDGE RD SUITE 100
RALEIGH NC
27607-6475
US

V. Phone/Fax

Practice location:
  • Phone: 919-881-9009
  • Fax: 919-881-8463
Mailing address:
  • Phone: 919-881-9009
  • Fax: 919-881-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9800163
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: